OF mental health care and mentally ill

Example Case Study of Schizophrenia

Example Case Study of Schizophrenia: Brian’s story History and experience

Brian is a young man who was diagnosed with learning disabilities at age 4. Brian and his family have lived for many years on a council housing estate in a close-knit inner-city community. Given Brian’s learning disability, he was marked as different from his older brother and sister at an early age. The family had been used to being involved with services as Brian had attended special school and a work programme for people with learning disability.

It was in the work programme, when Brian was 21 years of age, that his mental health problems were first noted. Having said this, he was initially thought to be having difficulties adjusting to the work placement following leaving school. At the time Brian’s problems were coming to light he moved into a shared home for people with learning disabilities. It was in this home he experienced his first episode of florid psychotic symptoms, believing that other people in the house were attempting to poison him as they knew he was the son of a famous gangster, which he was not. Brian’s family became so concerned that they took him back home, but his mental experiences did not change and he eventually needed admission, as he would stay up into the early hours to ‘protect his family from harm’. Eventually Brian was admitted to a special unit for people with mental health and learning disabilities.

This unit was sixty miles away from his family and this further heightened his paranoia. Following assessment, Brian was transferred to a local inpatient unit where he improved on an atypical antipsychotic. Brian was discharged following a CPA (care programme approach) meeting to a local mental health hostel. When his family went to visit him they again found him frightened and saying his room-mate was stealing his benefits and physically and verbally abusing him. Another resident verified Brian’s story and his family again took him back home, very angry at services. They refused to take Brian back to see his psychiatrist and insisted that all medication and treatment be coordinated through the local general practitioner (GP). Brian’s GP referred him and his family to a primary care mental health service run by a voluntary organization. The care plan for Brian and his family focused on assisting the family to care for him in their own home in order to build a rapport with them. On assessment, Brian was suspicious and had reverted to sitting up at night watching the house.

It was decided, given the effect his behaviour was having on the family, to meet him and his parents in joint sessions to address the wider family implications. Accordingly, the first sessions were spent in answering any questions the collective family members had regarding Brian’s diagnosis of schizophrenia. It soon became clear that neither Brian nor his parents were aware of the long-term effects of schizophrenia, and that a person with learning disabilities could experience psychotic symptoms. In these sessions the family also expressed confusion as to the increased number of professionals they now had to deal with.

Collaborative work

Brian’s suspicion transferred into his relationship with his care team. He would not talk in sessions, in spite of the best efforts of his family. After sessions, Brian would say that he was frightened that members of his care team wanted to ‘experiment on him’ or that the community nurse was motivated by homosexual feelings towards him. The family would then phone the care team to relate these feelings and talk about the strain caused by Brian’s suspicion. It was clear to the care team that the only way to maintain Brian in any form of collaborative work was through the family, and, in particular, his mother who was a dominant force within the family.

Working with a family system

In order to work with Brian, a series of family meetings aimed at assisting his family in their caring roles were conducted. While he remained a quiet, suspicious presence in these meetings, his family were encouraged to discuss their experience and concerns in front of him. Eventually, he was able to articulate his thought processes and related a series of both positive symptoms and realistic fears due to his experiences. The positive symptoms were mainly in the form of delusions of reference (various television programmes referred to Brian and his family), passivity phenomena, which led to Brian feeling that his body had been taken over by a ‘bad person with bad ideas’. The realistic fears were that he would be taken away from his family if he told people what he experienced. At this stage in the work, Brian’s mother related that she had a brother born with a severe learning disability who had been admitted into a learning disabilities hospital shortly after his birth and ‘abandoned’. The fear of separation, given the family’s life experiences and previous treatment decisions was viewed as realistic.

Medication

It was clear in the early stages of family meetings that Brian had stopped all forms of medication due to a mixture of suspicion that the medication was aimed at drugging him so that he could be ‘taken away’ (related to family members and not the care team) and side effects. The medication was reviewed and changed to an atypical drug under the supervision of his GP, whom he still trusted. The family was encouraged to administer and supervise the medication. After a few weeks, clear gains in Brian’s communication were being seen in meetings, and the family related that they were pleased with his response as there were no reported side effects.

Problem solving

The main area of concern, once the situation had been stabilized, was Brian’s lack of socialization outside of the family. A plan was made that Brian would leave the house for planned activities with his father and brother, with whom he felt safe. As this proved effective, Brain was encouraged to carry out small tasks in the locality to build his confidence. This proved very effective and, with the gains attributed to his taking regular effective medication, Brian began to leave the house by himself. There followed a period of unforeseen problems as Brian began to spend his days drinking alcohol in his room. His drinking became an issue as he would get intoxicated and get into arguments with family members.

Brain related that he was now bored and it was clear that he needed more focused activities during the day when other family members were at work.

Service problems

Both family and care team were frustrated by an inability to find appropriate activities for Brian. A mental health day unit proved to be unsuccessful as he was frightened of again being exploited and learning disability work and day units were uneasy at accepting him due to his mental health problems. In the process of working through these issues, Brian began to deteriorate. He was now at home for long periods by himself, continued to drink and began to omit medication doses. Eventually, following an argument with his sister during which the police were called, he was admitted to the local inpatient unit.

Conclusion

Following a short admission, Brian stabilized. He continued to remain well at home, but the struggle to find appropriate activities continued. At the time I left Brian’s care team it was clear that if a solution could not be found, he would continue to go through a sequence of improvement and relapse with his family bearing most of the caring role.